The rationale for a multimodal approach in the management of breakthrough cancer pain: a review

Pain Management in Oncology Patients Amidst the Opioid Epidemic: How To Minimize Non-Medical Opioid Use

The opioid epidemic continues to be a significant public health concern. On the surface, it appears difficult to understate the profound consequences and unnecessary loss of life at the hands of the opioid crisis throughout the 2010s. This reality should not dissuade rigorous attention toward those who have suffered unnecessarily due to an overreaching backlash toward the opioid crisis. Oncology patients have been significantly impacted on both ends of the opioid crisis. Like other populations, cancer patients were first affected during the initial surge of opioid availability, prescription, and use at the beginning of the crisis, where opioid abuse and overdose negatively impacted cancer patient populations at similar rates as the general population. Yet, cancer patients were perhaps even more heavily affected during secondary events after the initial crisis, as opioid restrictions and the stigmatization, undoubtedly beneficial in many spaces, of opioid use became prevalent across the American society. During this second period of the opioid crisis (loosely from 2013 to the present day after the Veterans Health Administration Opioid Safety Initiative started), restrictions on opioids have significantly decreased the use and access of opioids for cancer patients. Management of pain, in general, is a complex topic, and cancer pain is no exception. Cancer patients may experience pain related to the disease itself, its treatment, or other comorbidities. This review aims to clarify the impact of reducing opioid use on cancer patients over the past eight years. We summarize the challenges facing providers as they attempt to manage cancer-related pain. Additionally, we propose tools for best practices to reduce the unnecessary suffering of cancer patients and protect against the overuse and abuse of opioids.

Nonopioid drug combinations for cancer pain: protocol for a systematic review

This protocol will guide a review of clinical trials that evaluate the efficacy and safety of nonopioid analgesic drug combinations for the management of cancer-related pain.

Introduction:

Pain related to cancer, and its treatment, is common, may severely impair quality of life, and imposes a burden on patients, their families and caregivers, and society. Cancer-related pain is often challenging to manage, with limitations of analgesic drugs including incomplete efficacy and dose-related adverse effects.

Objectives:

Given problems with, and limitations of, opioid use for cancer-related pain, the identification of nonopioid treatment strategies that could improve cancer pain care is an attractive concept. The hypothesis that combinations of mechanistically distinct analgesic drugs could provide superior analgesia and/or fewer adverse effects has been tested in several pain conditions, including in cancer-related pain. Here, we propose to review trials of nonopioid analgesic combinations for cancer-related pain.

Methods:

Using a predefined literature search strategy, trials—comparing the combination of 2 or more nonopioid analgesics with at least one of the combination's individual components—will be searched on the PubMed and EMBASE databases from their inception until the date the searches are run. Outcomes will include pain intensity or relief, adverse effects, and concomitant opioid consumption.

Results/Conclusions:

This review is expected to synthesize available evidence describing the efficacy and safety of nonopioid analgesic combinations for cancer-related pain. Furthermore, a review of this literature will serve to identify future research goals that would advance our knowledge in this area.

125I brachytherapy in the palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments

Purpose

This study sought to assess the safety and effect of ¹²⁵I seed implantation for palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments.

Materials and Methods

89 patients with painful bone metastases secondary to lung cancer were consented and enrolled in this study from June 2013 to May 2015. All patients had failed or refused conventional treatments underwent percutaneous CT-guided ¹²⁵I seed implantation. The Brief Pain Inventory (BPI) was used to measure pain intensity prior to treatment (T₀), 2, 4, 6, 8 and 12 weeks (T₂, T₄, T₆, T₈ and T₁₂) after treatment in a 24-hour period. Analgesic, quality of life (QOL) scores and complications were also recorded. Four patients were excluded as they were lost to follow-up or had incomplete data.

Results

85 patients with 126 bone metastases from lung cancer were treated. There were significantly lower scores after treatment in the visual analog scale (VAS) and analgesic. The VAS scores for worst pain was 6.3±1.8 at T₀. At T₂, T₄, T₆, T₈ and T₁₂, the score in a 24-hour period decreased to 4.9±1.2 (P<0.01), 3.7±1.3 (P<0.01), 3.4±1.2 (P<0.01), 2.6±0.9 (P<0.01), and 1.4±0.8 (P<0.01) respectively. Comparison of QOL scores showed improvements including sleep, appetite, spiritual state, and fatigue at T₂, T₄, T₆, T₈ and T₁₂ when compared to T₀. No serious complications or massive bleeding were observed.

Conclusions

¹²⁵I brachytherapy is a safe and effective method for palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments.

Breakthrough pain in elderly patients with cancer: treatment options

The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.

Image-guided cryoablation for the treatment of painful musculoskeletal metastatic disease: a single-center experience

PURPOSE

The role of image-guided thermal ablation techniques for the nonoperative local management of painful osseous metastatic disease has expanded during recent years, and several advantages of cryoablation in this setting have emerged. The purpose of this study is to retrospectively evaluate and report a single-center experience of CT-guided percutaneous cryoablation in the setting of painful musculoskeletal metastatic disease.

METHODS

This study was approved by the institutional review board and is compliant with the Health Insurance Portability and Accountability Act. Electronic medical records of all patients who underwent percutaneous image-guided palliative cryoablation at our institution were reviewed (n = 61). An intent-to-treat analysis was performed. Records were reviewed for demographic data and anatomical data, primary tumor type, procedure details, and outcome-including change in analgesic requirements (expressed as morphine equivalent dosages), pain scores (utilizing the clinically implemented visual analog scale), subsequent therapies (including radiation and/or surgery), and complications during the 24 h following the procedure and at 3 months. Patients were excluded (n = 7) if data were not retrospectively identifiable at the defined time points.

RESULTS

Fifty-four tumors were ablated in 50 patients. There were statistically significant decreases in the median VAS score and narcotic usage at both 24 h and 3 months (p < 0.000). Six patients (11%) incurred complications related to their therapy. Two patients had no relief at 24 h, of which both reported worsened pain at 3 months. One patient had initial relief but symptom recurrence at 3 months. Four patients went on to have radiation therapy of the ablation site at some point following the procedure.

CONCLUSIONS

CT-guided cryoablation is a safe, effective, reproducible procedural option for the nonoperative local treatment of painful musculoskeletal metastatic disease.

Intravenous paracetamol as an antipyretic and analgesic medication: the significance of drug metabolism

One prospective, open-label, non-randomized study was conducted in 100 patients to define the antipyretic and analgesic effect of a new intravenous formulation of 1 g of paracetamol; 71 received paracetamol for the management of fever and 29 received paracetamol for pain relief after abdominal surgery or for neoplastic pain. Serial follow-up measurements of core temperature and of pain intensity were done for 6 h. Additional rescue medications were recorded for 5 days. Blood was sampled for the measurement of free paracetamol (APAP) and of glucuronide-APAP and N-sulfate-APAP by an HPLC assay. Defervescence, defined as core temperature below or equal to 37.1°C, was achieved in 52 patients (73.2%) within a median time of 3 h. Patients failing to become afebrile with the first dose of paracetamol became afebrile when administered other agents as rescue medications. Analgesia was achieved in 25 patients (86.4%) within a median time of 2 h. Serum levels of glucuronide-APAP were greater among non-responders to paracetamol. The presented results suggest that the intravenous formulation of paracetamol is clinically effective depending on drug metabolism.

Cancer Pain: A Critical Review of Mechanism-based Classification and Physical Therapy Management in Palliative Care

Mechanism-based classification and physical therapy management of pain is essential to effectively manage painful symptoms in patients attending palliative care. The objective of this review is to provide a detailed review of mechanism-based classification and physical therapy management of patients with cancer pain. Cancer pain can be classified based upon pain symptoms, pain mechanisms and pain syndromes. Classification based upon mechanisms not only addresses the underlying pathophysiology but also provides us with an understanding behind patient's symptoms and treatment responses. Existing evidence suggests that the five mechanisms – central sensitization, peripheral sensitization, sympathetically maintained pain, nociceptive and cognitive-affective – operate in patients with cancer pain. Summary of studies showing evidence for physical therapy treatment methods for cancer pain follows with suggested therapeutic implications. Effective palliative physical therapy care using a mechanism-based classification model should be tailored to suit each patient's findings, using a biopsychosocial model of pain.

[Experiences of cancer patients with breakthrough pain and pharmacological treatments]

BACKGROUND

of cancer patients receiving palliative care, 80% suffer from cancer pain, and again 80% of these patients report breakthrough pain. This study explores the patients' perception of breakthrough pain, their experiences with existing therapeutic regimens and their expectations regarding an ideal breakthrough pain medication.

METHOD

from November 2008 to February 2010 two German palliative care units recruited 80 in- or outpatient cancer patients who completed a standardized questionnaire on breakthrough pain characteristics, analgesic medication, attitudes towards new treatment approaches for breakthrough pain, and experiences with alternative routes of drug administration as part of the "European Survey of Oncology Patients' Experience of Breakthrough Pain".

RESULTS

the study participants suffered from 1-12 episodes of either incident (47.5%) or spontaneous pain (37.5%) per day which were perceived as "severe" in 71% of all cases. These exacerbations highly interfered with the patients' general activity, mood, walking ability, and normal work. Overall, 64% of the patients reported alleviation from pharmacological (26%) and non-pharmacological (73%) interventions. Subcutaneous (40%) and oral (39%) routes were used frequently; intranasal (1.25%) and intrapulmonary (1.25%) routes were used rarely. Only 64% of all participants stated an overall satisfaction with their breakthrough analgesia.

CONCLUSION

the diagnosis and treatment of breakthrough pain seems to be conducted in a suboptimal manner, and standard recommendations on breakthrough pain relief are not implemented consistently. Possible causes of pain should be taken into account as well as multi-professional treatment interventions and alternative routes of administration of fast onset, effective drugs should be considered.